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_ WELUPUMP PERMIT <br /> SAN JOAOIIIV COUNTY ENVIRONMENTAL HEALTH DEPART1rENT 600 EAST MAIN STREET-STOCKTON CA 95202-(209)460J42D <br /> NON-REFUNDABLE PERMIT /� /)r. /1CA1Lr�1Lr 2009)9153-7697 FOR INSPECTIONS EXPIRES 11YYEAR <br /> �I"DATE ISSUED <br /> Joe ADORM -I d,! Y u T 1 Au t/1 I---- Cr"'r" S c a l(// ! 1 r73)-o I'� <br /> CROS STREET �^•7� y� I ) pAPN�,LS� �BO ��PARCEL SIZE APP JCA710N C � <br /> OWNER NAME )))���✓��'///��,---///���1 7 V(�l_ PHOnE . <br /> A.. Vjh Yc e Cn^r/STATEILP rc, qrD ' <br /> ON <br /> CONTRACTOR .`'--if{,' <br /> `�J u-• L P'�H{{ E I <br /> CONTRACTOR ADDRE49 Vl IA l ll4 P YISTATEIIP U <br /> SUBCONTRACTOR N I PHONE <br /> SUBCONTRACTOR AOOTESS "" /• T CITYJ-1 <br /> S/TA� Z <br /> TEP ) <br /> LICENSE I C•57 XC61 1 0-09 Other_�ZL— Nu— i/ lExPrRAnON DAT--) / <br /> GEOGRAPHICAL INFORMATION: Coordlnatea X Y Township_ Range Section_ <br /> WrENOED UsE J D0nteSbC1Private L Irrigation/Agnallturtil F Industrial ,Water Quality Monitoring = Soil Sampling/Characterization <br /> Public Water System <br /> H 0e%—I from Own•. em nr uomact Nam* conn - <br /> TYPE OF YIFORK 'l New Wa Li Replacement Welt - Well AlterstioniModification ]Other <br /> 4on�lo ring Well(s) t of wets c Sall Soring(s) eorbodnp _ Geotechnical f p1 <br /> Out-0 Service Well 17 Out-Of-Soria Well Renewid D Cross-Connection Repair <br /> MILL CQf*hyCb -Neer urs_ -1 P Rip aoement C Puinp Repair —T C Riise wen-casing - — <br /> Drilling Method Mud Rotary D Air Rotary I_ Auger 7 Cable Tod D Push Point l Other <br /> i <br /> Proposed Well Depot h Excavation in diameter O Open Bottom []Gravel PaWGravel Size in diameter:I <br /> Conductor Casing in diameter / Conductor Cuing Depth R <br /> Well Casing Diameter_in Thidmess/GaugelASTM Scheel U Stec! C Plastic r Stainless Steel Il Other <br /> Grout Seal Depth_ft r;Neat Cement!94 lb bag S-10 pal water) !I Send Cement sack miv7 gel water <br /> Bentonile(2D%Solids) 7 <br /> GroutOther <br /> Placement Method :Punged u Free Fal u Other i Retardant/Accelerator(name) <br /> PEDESTAL installed By h:Driller D Pump Contractor —Other - <br /> J Concrete Pedestal-Dimensions:Width It Length _.�ft Thick in D Christy Box G Stave PI <br /> Submersible U Turbine 73 Other HP 11 Punrp Set ft Standing Water Level 9 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE is <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> I <br /> MINIMU 24 HOUR ADVANCE NOTICE REQUIRED FOR IN PECTIONS <br /> SW.TED TrtLE DATE <br /> - i <br /> -D <br /> 13 <br /> uN-ry <br /> { I ! <br /> ilk I I IE MENT- <br /> _ I Ll <br /> - - - - - - - <br /> SVT <br /> 013 <br /> I urvn► <br /> DEPARTM USE ONLY p II �,-. /f_' <br /> J <br /> Application Accepted By 09 ��� Area /Employee Ilii�fL!. Td J f <br /> Grout Inspection By TT SPECIAL WBII POFMIt // <br /> Pump Inspti <br /> econ By Date d a WAIVER Recei red <br /> So.l Boring I By Date_ - Conslnitted Wall Depth R <br /> COMMENTS <br /> PE SIC Received het Amount Permit! , Invoice a Wolf loo <br /> Codes Into ash Remitted 9810 Service,Roquaato <br /> EI�.300 WfI..lPIRM 7ERM:T <br /> NO.Ia6 <br />